TY - JOUR
T1 - Dobutamine Stress Echocardiography for Management of Low-Flow, Low-Gradient Aortic Stenosis
AU - Annabi, Mohamed Salah
AU - Touboul, Eden
AU - Dahou, Abdellaziz
AU - Burwash, Ian G.
AU - Bergler-Klein, Jutta
AU - Enriquez-Sarano, Maurice
AU - Orwat, Stefan
AU - Baumgartner, Helmut
AU - Mascherbauer, Julia
AU - Mundigler, Gerald
AU - Cavalcante, João L.
AU - Larose, Éric
AU - Pibarot, Philippe
AU - Clavel, Marie Annick
N1 - Funding Information:
This work was supported by a grant (# MOP-57445 for TOPAS-II and # MOP-126072 and FDN-143225 for TOPAS-III) from the Canadian Institutes of Health Research, Ottawa, Canada. Dr. Dahou was supported by a fellowship grant from “L’Agence de la santé et des services sociaux de la Capitale nationale-ADLSSS”, Québec, Québec, Canada. Dr. Pibarot holds the Canada Research Chair in Valvular Heart Diseases, Canadian Institutes of Health Research; and has received institutional research support from Edwards Lifesciences and Medtronic. Dr. Clavel holds a junior scholarship from Fonds de Recherche du Québec-Santé (FRQS).
Funding Information:
Dr. Dahou has received a research grant from Grant Edwards LLC. Dr. Baumgartner has received travel support from Edwards Lifesciences, Medtronic, Abbott, and Actelion; and has received speaker fees from Edwards Lifesciences. Dr. Cavalcante has received a research grant from Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Annabi and Touboul contributed equally to this work and are joint first authors on this paper.
Publisher Copyright:
© 2018 American College of Cardiology Foundation
PY - 2018/2/6
Y1 - 2018/2/6
N2 - Background: In the American College of Cardiology/American Heart Association guidelines, patients are considered to have true-severe stenosis when the mean gradient (MG) is ≥40 mm Hg with an aortic valve area (AVA) ≤1 cm2 during dobutamine stress echocardiography (DSE). However, these criteria have not been previously validated. Objectives: The aim of this study was to assess the value of these criteria to predict the presence of true-severe AS and the occurrence of death in patients with low-flow, low-gradient aortic stenosis (LF-LG AS). Methods: One hundred eighty-six patients with low left ventricular ejection fraction (LVEF) LF-LG AS were prospectively recruited and underwent DSE, with measurement of the MG, AVA, and the projected AVA (AVAProj), which is an estimate of the AVA at a standardized normal flow rate. Severity of AS was independently corroborated by macroscopic evaluation of the valve at the time of valve replacement in 54 patients, by measurement of the aortic valve calcium by computed tomography in 25 patients, and by both methods in 8 patients. According to these assessments, 50 of 87 (57%) patients in the study cohort had true-severe stenosis. Results: Peak stress MG ≥40 mm Hg, peak stress AVA ≤1 cm2, and the combination of peak stress MG ≥40 mm Hg and peak stress AVA ≤1 cm2 correctly classified AS severity in 48%, 60%, and 47% of patients, respectively, whereas AVAProj ≤1 cm2 was better than all the previous markers (p < 0.007), with 70% correct classification. Among the subset of 88 patients managed conservatively (47% of the cohort), 52 died during a follow-up of 2.8 ± 2.5 years. After adjustment for age, sex, functional capacity, chronic kidney failure, and peak stress LVEF, peak stress MG and AVA were not predictors of mortality in this subset. In contrast, AVAProj ≤1 cm2 was a strong predictor of mortality under medical management (hazard ratio: 3.65; p = 0.0003). Conclusions: In patients with low LVEF LF-LG AS, the DSE criteria of a peak stress MG ≥40 mm Hg, or the composite of a peak stress MG ≥40 mm Hg and a peak stress AVA ≤1 cm2 proposed in the guidelines to identify true-severe AS and recommend valve replacement, have limited value to predict actual stenosis severity and outcomes. In contrast, AVAProj better distinguishes true-severe AS from pseudo-severe AS and is strongly associated with mortality in patients under conservative management. (Multicenter Prospective Study of Low-Flow Low-Gradient Aortic Stenosis [TOPAS]; NCT01835028)
AB - Background: In the American College of Cardiology/American Heart Association guidelines, patients are considered to have true-severe stenosis when the mean gradient (MG) is ≥40 mm Hg with an aortic valve area (AVA) ≤1 cm2 during dobutamine stress echocardiography (DSE). However, these criteria have not been previously validated. Objectives: The aim of this study was to assess the value of these criteria to predict the presence of true-severe AS and the occurrence of death in patients with low-flow, low-gradient aortic stenosis (LF-LG AS). Methods: One hundred eighty-six patients with low left ventricular ejection fraction (LVEF) LF-LG AS were prospectively recruited and underwent DSE, with measurement of the MG, AVA, and the projected AVA (AVAProj), which is an estimate of the AVA at a standardized normal flow rate. Severity of AS was independently corroborated by macroscopic evaluation of the valve at the time of valve replacement in 54 patients, by measurement of the aortic valve calcium by computed tomography in 25 patients, and by both methods in 8 patients. According to these assessments, 50 of 87 (57%) patients in the study cohort had true-severe stenosis. Results: Peak stress MG ≥40 mm Hg, peak stress AVA ≤1 cm2, and the combination of peak stress MG ≥40 mm Hg and peak stress AVA ≤1 cm2 correctly classified AS severity in 48%, 60%, and 47% of patients, respectively, whereas AVAProj ≤1 cm2 was better than all the previous markers (p < 0.007), with 70% correct classification. Among the subset of 88 patients managed conservatively (47% of the cohort), 52 died during a follow-up of 2.8 ± 2.5 years. After adjustment for age, sex, functional capacity, chronic kidney failure, and peak stress LVEF, peak stress MG and AVA were not predictors of mortality in this subset. In contrast, AVAProj ≤1 cm2 was a strong predictor of mortality under medical management (hazard ratio: 3.65; p = 0.0003). Conclusions: In patients with low LVEF LF-LG AS, the DSE criteria of a peak stress MG ≥40 mm Hg, or the composite of a peak stress MG ≥40 mm Hg and a peak stress AVA ≤1 cm2 proposed in the guidelines to identify true-severe AS and recommend valve replacement, have limited value to predict actual stenosis severity and outcomes. In contrast, AVAProj better distinguishes true-severe AS from pseudo-severe AS and is strongly associated with mortality in patients under conservative management. (Multicenter Prospective Study of Low-Flow Low-Gradient Aortic Stenosis [TOPAS]; NCT01835028)
KW - LV dysfunction
KW - aortic stenosis
KW - stress echocardiography
KW - survival
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U2 - 10.1016/j.jacc.2017.11.052
DO - 10.1016/j.jacc.2017.11.052
M3 - Article
C2 - 29406851
AN - SCOPUS:85044856351
VL - 71
SP - 475
EP - 485
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
SN - 0735-1097
IS - 5
ER -